SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes

OBJECTIVES

To understand SARS-Co-V-2 infection and transmission in UK nursing homes in order to develop preventive strategies for protecting the frail elderly residents.

METHODS

An outbreak investigation involving 394 residents and 70 staff, was carried out in 4 nursing homes affected by COVID-19 outbreaks in central London. Two point-prevalence surveys were performed one week apart where residents underwent SARS-CoV-2 testing and had relevant symptoms documented. Asymptomatic staff from three of the four homes were also offered SARS-CoV-2 testing.

RESULTS

Overall, 26% (95% CI 22-31) of residents died over the two-month period. All-cause mortality increased by 203% (95% CI 70-336) compared with previous years. Systematic testing identified 40% (95% CI 35-46) of residents as positive for SARS-CoV-2, and of these 43% (95% CI 34-52) were asymptomatic and 18% (95% CI 11-24) had only atypical symptoms; 4% (95% CI -1 to 9) of asymptomatic staff also tested positive.

CONCLUSIONS

The SARS-CoV-2 outbreak in four UK nursing homes was associated with very high infection and mortality rates. Many residents developed either atypical or had no discernible symptoms. A number of asymptomatic staff members also tested positive, suggesting a role for regular screening of both residents and staff in mitigating future outbreaks.

Treatment of Progressive Systemic Sclerosis by Plasma Exchange: Long-term Results in 40 Patients

The efficacy of plasma exchanges (PE) during the course of scleroderma has only been investigated for short periods. The aim of this study was to follow patients over a long enough period to observe the course of the clinical and paraclinical symptoms in the short, medium, and long term. Forty patients, 24 women and 16 men, were treated by PE and observed for 1–3, 3–12 and over 12 months. Immunological, biological and clinical course and any undesirable side effects were evaluated using a detailed questionnaire. Concomitant therapies were reported and most frequently consisted of corticosteroids, colchicine, factor XIII or vasodilators (nifedipine, captopril). The therapeutic effectiveness of PE was assessed on the basis of improvements in cutaneous, digestive, joint, muscular, lung, cardiovascular and renal lesions. Our findings confirmed the effectiveness of short-term PE on scleroderma (52% of the patients improved during the first 3 months). However, this improvement was transient (5% improvement between 3 and 12 months and only 2.5% over 12 months) and limited to the cutaneous and muscular lesions. Thus, PE cannot be recommended for the treatment of progressive systemic sclerosis.

Evaluation of prediagnosis emergency department presentations in patients with active tuberculosis: the role of chest radiography, risk factors and symptoms

INTRODUCTION

London has a high rate of tuberculosis (TB) with 2572 cases reported in 2014. Cases are more common in non-UK born, alcohol-dependent or homeless patients. The emergency department (ED) presents an opportunity for the diagnosis of TB in these patient groups. This is the first study describing the clinico-radiological characteristics of such attendances in two urban UK hospitals for pulmonary TB (PTB) and extrapulmonary TB (EPTB).

METHODS

We conducted a retrospective cohort study using the London TB Register (LTBR) and hospital records to identify patients who presented to two London ED's in the 6 months prior to their ultimate TB diagnosis 2011-2012.

RESULTS

397 TB cases were identified. 39% (154/397) had presented to the ED in the 6 months prior to diagnosis. In the study population, the presence of cough, weight loss, fever and night sweats only had prevalence rates of 40%, 34%, 34% and 21%, respectively. Chest radiography was performed in 76% (117/154) of patients. For cases where a new diagnosis of TB was suspected, 73% (41/56) had an abnormal radiograph, compared with 36% (35/98) of patients where it was not. There was an abnormality on a chest radiograph in 73% (55/75) of PTB cases and also in 40% (21/52) of EPTB cases where a film was requested.

CONCLUSIONS

A large proportion of patients with TB present to ED. A diagnosis was more likely in the presence of an abnormal radiograph, suggesting opportunities for earlier diagnosis if risk factors, symptoms and chest radiograph findings are combined.

Circulating endothelial cells and progenitors as prognostic factors during autoimmune thrombotic thrombocytopenic purpura: results of a prospective multicenter French study

BACKGROUND

Autoimmune thrombotic thrombocytopenic purpura (AI-TTP) is characterized by an excess of circulating ultralarge von Willebrand factor (VWF) caused by anti-ADAMTS-13 autoantibodies. Animal studies, however, have shown that endothelial cell activation may also be an important trigger of AI-TTP.

OBJECTIVES

To prospectively study circulating biomarkers of endothelial lesion and activation, such as circulating endothelial cells (CECs), soluble P-selectin (sP-selectin), or VWF, and of endothelial repair, such as circulating progenitor cells (CPCs) and endothelial progenitor cells (EPCs), in AI-TTP, in relation to disease severity and prognosis.

RESULTS

Twenty-two patients were included in this study. CEC (P < 0.01), VWF (P < 0.05) and sP-selectin (P < 0.01) levels were significantly increased during crisis, and returned to baseline levels during remission. Both CEC (P < 0.05) and sP-selectin (P < 0.05) levels were significantly higher in patients who died or developed neurologic sequelae. CPC levels were substantially increased during the acute phase of the disease (P < 0.001), and returned to baseline levels during remission. Among CPCs, EPC levels were also increased during crisis (P < 0.05) and significantly decreased during remission. Patients who received < 16 plasma exchanges (PEs) had significantly higher EPC counts (P < 0.05) than those who needed more numerous PEs to obtain remission, suggesting that initial EPC counts may be associated with faster endothelial repair.

CONCLUSION

The profile of circulating endothelial markers shows massive endothelial activation and repair/remodeling during AI-TTP, and suggests that CECs and EPCs may be promising prognostic biomarkers of the disease.

Management of suspected viral encephalitis in adults--Association of British Neurologists and British Infection Association National Guidelines

In the 1980s the outcome of patients with herpes simplex encephalitis was shown to be dramatically improved with aciclovir treatment. Delays in starting treatment, particularly beyond 48 h after hospital admission, are associated with a worse prognosis. Several comprehensive reviews of the investigation and management of encephalitis have been published. However, their impact on day-to day clinical practice appears to be limited. The emergency management of meningitis in children and adults was revolutionised by the introduction of a simple algorithm as part of management guidelines. In February 2008 a group of clinicians met in Liverpool to begin the development process for clinical care guidelines based around a similar simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.

The microbiological basis for a revised antibiotic regimen in high-energy tibial fractures: preventing deep infections by nosocomial organisms

BACKGROUND

Deep surgical site infections (SSI's) complicate Gustilo IIIB tibial fractures in 8-13% of cases. Antibiotic prophylaxis typically covers environmental contaminants. However, nosocomial organisms are usually implicated in deep infection. We used the microbiological profile of infected Gustilo IIIB tibial fractures to define a new, dynamic prophylactic regimen which recognises the need for prophylaxis against nosocomial organisms at the time of definitive closure.

METHODS

The microbiological profiles of Gustilo IIIB tibial fractures presenting over a 2-year period from January 2006 to December 2007 were reviewed. The environmental contaminants were compared with the organisms isolated from deep SSI's and correlated with the prophylactic antibiotic regimen used.

RESULTS

Fifty-two patients were included. Nine developed a deep tissue infection. The pathogens implicated included resistant Enterococci, Pseudomonas, Enterobacter and MRSA. Standard antibiotic prophylaxis provided cover for these combinations in only one of nine cases. This would have improved to eight of nine cases with the use of teicoplanin and gentamicin, given as a one-time dose during definitive soft-tissue closure. Specimens taken from wound debridement were neither sensitive nor specific for the subsequent development of deep infection and did not predict the organisms responsible.

CONCLUSIONS

Following high-energy open fracture, a single prophylactic antibiotic regimen directed against environmental wound contaminants does not provide cover for the organisms responsible for deepest SSI's and may have depopulated the niche, promoting nosocomial contamination prior to definitive closure. We advocate a dynamic prophylactic strategy, tailoring a second wave of prophylaxis against nosocomial organisms at the time of definitive wound closure, and at the same time avoiding the potential complications of prolonged antibiotic use.

Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: prevalence and outcome

AIMS

To determine the prevalence, clinical characteristics, and outcome of hypoglycaemia on admission in children at a rural Kenyan district hospital.

METHODS

Observational study of 3742 children (including 280 neonates) in Kilifi District Hospital, Kenya.

MAIN OUTCOME MEASURES

hypoglycaemia (blood glucose <2.2 mmol/l) and hyperglycaemia (blood glucose >10.0 mmol/l).

RESULTS

Non-neonates: the prevalence of hypoglycaemia on admission was 7.3%. Severe illness, malnutrition, last meal >12 hours ago, and a positive malaria slide were independently associated with hypoglycaemia. Overall, mortality in hypoglycaemic children was 20.2% compared to 3.8% in normoglycaemic children (p < 0.001). The brunt of mortality in hypoglycaemic children was borne by those who were severely ill or malnourished (31.8%) as opposed to those who were neither severely ill nor malnourished (9.0%). Neonates: 23.0% of neonates were hypoglycaemic on admission. Inability to breast feed and weight <2500 g were independently associated with hypoglycaemia. Mortality was 45.2% compared to 19.6% in normoglycaemic neonates (p < 0.001). Hyperglycaemia was present in 2.7% of children and was associated with a higher mortality than normoglycaemia, 14.0% versus 3.8% respectively (p < 0.001).

CONCLUSIONS

Hypoglycaemia is common in children admitted to a rural Kenyan district hospital and is associated with an increased mortality. Apart from features of severe illness and poor feeding, clinical signs have a low sensitivity and specificity for hypoglycaemia. Where diagnostic facilities are lacking, presumptive treatment of severely ill children is recommended. For other children, the continuation of feeding (by nasogastric tube if necessary) should be part of standard management.

Maternal rubella-specific antibody prevalence in Ethiopian infants

In countries with a high transmission rate of rubella the optimal age for universal rubella vaccination of infants is critically dependent upon the rate of loss of maternal antibodies. Few studies have investigated the decay characteristics of such antibodies. Mother:infant pairs were recruited at the Ethio-Swedish Children's Hospital, Addis Ababa, in 1994/95. Rubella antibody levels, determined by radial haemolysis, were available for analysis from 1542 infants aged 0-12 months, with 942 repeat measures, and from 846 mothers. Decay in seropositivity was well described by a delayed exponential function. The proportion seropositive at age 6, 9, or 12 months was 6-13%, 1-4%, or 0-1%, respectively, dependent upon assay cutoff level. Only infant age and mother's antibody level were important predictors of seropositivity. Results suggest that the success of vaccination at age 9 months or above would be little affected by residual maternal antibodies.

New therapies and changing patterns of treatment for malaria

The launch of the Roll Back Malaria initiative by the World Health Organization in the period under review confirms malaria's place as one of the great public health priorities worldwide. The period 1998-1999 has seen some advances and some disappointments in the treatment of malaria, against a backdrop of spreading drug resistance. Most encouraging is the clear demonstration that intermittent prospective treatment of asymptomatic pregnant women in endemic areas reduces morbidity. The greatest disappointment has been the result of trials with the artemether-benflumetol fixed-dose combination therapy. Questions have been raised about several widely accepted practices, including measurement of quinine levels, exchange transfusion, and the prophylactic use of anticonvulsants in children with cerebral malaria.

Acquired hemophilia due to factor VIII inhibitors in 34 patients

BACKGROUND

Acquired hemophilia is a rare disease caused by the development of auto-antibodies against factor VIII.

SUBJECTS AND METHODS

We studied the characteristics and outcomes of 34 patients (19 women and 15 men) with acquired hemophilia from 1980 to 1997.

RESULTS

The mean age of the patients was 61 years (range, 22-93 years). An underlying disease was observed in 18 (53%) patients: 5 patients had cancer, 4 an autoimmune disorder, 2 a dermatologic disorder, 3 asthma, 3 were postpartum, and 1 had an adverse reaction to ampicillin. Factor VIII level was <5% in 30 (90%) patients; factor VIII antibodies were elevated (>10 Bethesda units) in 23 (69%) patients. Bleeding requiring transfusions was reported in 25 (75%) patients. Human factor VIII was given to 14 patients and porcine factor VIII to 5. Six patients received prothrombin complex concentrates and one desmopressin. Several immunosuppressive treatments were used, mainly corticosteroids, cyclophosphamide, and intravenous immunoglobulin. Bleeding stopped in all but one patient within 2 weeks. Most patients achieved complete remission, although two relapses were observed subsequently.

CONCLUSION

This large study helps to clarify the presentation and clinical course of acquired hemophilia. Prospective studies are needed to determine the efficacy of treatment.

[Lung cancer in patients infected with human immunodeficiency virus. Clinical course and therapeutic implications]

OBJECTIVES

HIV infection is associated with increased frequency of non-Hodgkin's lymphoma and Kaposi sarcoma. Like other malignancies, lung cancer has been described in HIV-infected patients although no evidence of a statistical correlation has been reported.

PATIENTS AND METHODS

We performed a retrospective analysis of 15 HIV-infected patients with lung cancer. The patients were relatively younger (mean age 45 years) than is commonly found in lung cancer cohorts.

RESULTS

The 15 patients had mild immunodepression (240 CD4+/mm3) and were in advanced clinical stage at diagnosis. Mean overall survival was 6 months and no clinical or biological prognostic factors were found. Death was usually due to infection, suggesting a synergetic effect between HIV and chemotherapy-induced immunodepression.

CONCLUSION

We propose early antiretroviral therapy in cases of chemotherapy-treated HIV patients, even when commonly accepted immunological and/or clinical criteria are absent.

HLA-DM and MHC class II molecules co-distribute with peptidase-containing lysosomal subcompartments

MHC class II molecules associate with peptides in the endocytic pathway. Different endosomal locations for peptide loading of class II molecules, varying from early endosomes (EE) to lysosomes, have been assigned on the basis of subcellular fractionation experiments. We have determined the intracellular location of HLA-DM, a molecule that supports peptide loading of class II molecules, by separating vesicles from the melanoma cell line Mel JuSo on the basis of buoying density and surface charge. In both fractionations, HLA-DM co-fractionated with a lysosomal compartment containing beta-hexosaminidase (beta-hex) activity and not with endosomes. Further analysis showed that HLA-DM mainly co-fractionated with a sub-lysosomal structure characterized by a relative low density and containing both pro- and mature cathepsin D and MHC class II molecules. Fluid phase markers first enter this compartment before entering high-density lysosomes that contain exclusively mature cathepsin D, some HLA-DM and no detectable MC class II molecules. Finally we determined the intracellular location of neutral and acidic peptidases. Whereas neutral peptidase activity was detected in the endoplasmic reticulum and/or plasma membrane fractions, acidic peptidase activity exclusively migrated at the position of HLA-DM containing lysosomal vesicles. Our results show that class II molecules co-migrate with HLA-DM, pro- and mature cathepsin D, beta-hex and acidic peptidase activity. HLA-DM, cathepsin d and class II molecules were not observed at the position of EE. Our data suggest that HLA-DM-mediated peptide loading of class II molecules occurs in a lysosomal subcompartment.

Organisation and functions of class II genes and molecules

The class II region of the human MHC contains all of the known class II genes: as well as antigen processing components and only one gene not obviously associated with the immune system, RING3. As an approach to understanding linkage disequilibrium and recombination in relation to polymorphism of the region we are cloning and sequencing the class II region. To date, the sequence of the DP-DQ region has almost been completed (see Report by S. Beck). Several sets of genes implicated in the immune system, especially in antigen processing and presentation, are clustered together in the MHC: class I (HLA-A, B, C etc) class II (DR, DQ, DP, DN, DO, DM) LMP2 and 7, TAP1 and 2, TNF, C2, C4, Bf, Hsp70. This situation has provoked speculation that the MHC behaves as a gene cluster in which allelic products of polymorphic genes are maintained on a haplotype so as to co-ordinate T cell repertoire development and deployment. The high levels of linkage disequilibrium across the region are consistent with this idea. Functions of the genes in the MHC are being investigated as a step towards gaining insight into antigen processing and presentation as well as understanding MHC-disease associations. We are concentrating on the functions of the class II-related genes, DM and DN/DO as well as the TAP/LMP cluster.

Association between HLA-DM and HLA-DR in vivo

The exchange of HLA class II-associated invariant chain peptides (CLIP) for cognate peptide is catalyzed by HLA-DM under acidic conditions in vitro by an unknown mechanism. Here, we show an association between HLA-DM and HLA-DR in vivo by coprecipitation of the two heterodimers. The association is favored at low pH and in the nonionic detergent digitonin. Most DM-DR complexes are isolated from dense subcellular fractions. Recovery of HLA-DM by the conformation-dependent DR3 monoclonal antibody 16.23 suggests an association with HLA-DR heterodimers beyond the stage at which CLIP is released. The additional N-linked glycan on mutant DR3 molecules isolated from the 10.24.6 cell line, which interferes with DM-enhanced CLIP release from DR3 in vitro, also affects the DM-DR interaction.

Accumulation of HLA-DM, a regulator of antigen presentation, in MHC class II compartments

The HLA-DM genes encode an unconventional HLA (human leukocyte antigen) class II molecule that is required for appropriate binding of peptide to classical HLA class II products. In the absence of DM, other class II molecules are unstable upon electrophoresis in sodium dodecyl sulfate and are largely associated with a nested set of peptides derived from the invariant chain called CLIP, for class II-associated invariant chain peptides. DMA and DMB associated and accumulated in multilaminar, intracellular compartments with classical class II molecules, but were found infrequently, if at all, at the cell surface. Thus, DM may facilitate peptide binding to class II molecules within these intracellular compartments.

The use of inpatient admission privileges by members of a division of general practice

OBJECTIVE

The Mornington Peninsula Hospital (MPH) in Victoria has a Division of General Practice whose members retain admission privileges. We will describe the use of general practitioner inpatient admitting rights at Mornington Peninsula Hospital.

METHOD

The study will be a retrospective review of existing hospital databases.

RESULTS

From 1980 until July 1992 the rate of general practitioner admissions is decreasing at one per cent per annum. Comparative data shows an increase of 0.7 per cent in admissions per annum by medical specialists. Between 1988 and 1991 general practitioner admissions have been equally divided between obstetrics and general medicine. The proportion of long stay general practitioner inpatients is below one per cent of all general practitioner admissions, and the average length of stay for general practitioner inpatients approximates that of MPH in general. Most general practitioner inpatients are discharged home, and 3.1 per cent are transferred to other units or hospitals. Neoplastic disease accounts for 40 per cent of all the deaths within the general practitioner inpatient group.

DISCUSSION

This study shows that, in selected areas, the care of inpatients is still a valid role for some general practitioners.

Paraneoplastic Raynaud's phenomenon

A testicular tumour could be diagnosed by the occurrence of a Raynaud's phenomenon complicated by severe digital arteritis. The arteritis rapidly regressed under prostacyclin therapy. Such vascular manifestations are frequent in testicular carcinoma, but they usually develop after chemotherapy. To our knowledge, this is the first case where they preceded the diagnosis and specific treatment of a tumour of the testis.